• Assess the person in terms of:
• Factors contributing to their overweight or obesity.
• Risk of health problems in the future.
• Their willingness to address their weight.
• Advise on diet and physical activity.
• Refer if appropriate.
• Otherwise, manage according to body mass index (BMI), waist circumference (if BMI < 35 kg/m²), and comorbidities.
• Prescribe an anti-obesity drug if appropriate.
• Consider referral for surgery if the person fulfils the criteria.

• Assess:
• Underlying causes and comorbidities (e.g. medical problems, medication, psychological and social factors).
• Risk of developing complications of obesity (e.g. medical or psychological).
• Lifestyle in terms of diet and exercise.
• The potential health benefits of weight loss to the person.
• The person's feelings about being overweight (e.g. beliefs, previous attempts to lose weight, and what was learnt).
• The person's willingness and motivation to try to lose weight.

• This recommendation is based on guidance from the National Institute for Health and Clinical Excellence (NICE) on the prevention, identification, assessment, and management of overweight and obesity in adults and children [NICE, 2006b] and the care pathway for the management of overweight and obesity from the Department of Health [DH, 2006a].
• NICE looked at the evidence for the common comorbidities in adults who are overweight or obese, and the effectiveness of weight loss in these people, along with their expected health gain [National Collaborating Centre for Primary Care, 2006].

• Healthcare professionals should use clinical judgement when deciding whether to measure a person's height and weight, but opportunities include when a person registers at the practice and at consultations for conditions related to obesity (e.g. type 2 diabetes and cardiovascular disease).
• Approach the subject of weight carefully because people who are overweight or obese may be sensitive about discussing it, or feel that their presenting problem is being overlooked.
• Initiate a conversation about the person's weight if they appear to be overweight or obese and there are no reasons why this should not be discussed.
• For example, offer to discuss their height and weight measurements, and if their body mass index is in the overweight or obese category, discuss the possible health implications of this.
• Explain why excess weight can be problematic in terms of comorbidities and the chance of developing complications.
• Discuss why gaining more weight may increase risks to health.
• Make the person aware of the benefits of modest weight loss with regard to comorbidities and disease risk, particularly if they are obese (see Table 1).

• This recommendation is based on the Department of Health Care Pathway for the management of overweight and obesity [DH, 2006a].

History:

• Medical history:
• Enquire into medical conditions that can contribute to overweight and obesity, or complications that may arise as a result of excess weight.
• Pay particular attention to symptoms of comorbidities that might not be recognized (e.g. sleep apnoea).
• Family history (e.g. family history of overweight and obesity, and comorbidities).
• Drug history — identify medication that might cause weight gain.
• Social history (e.g. lifestyle, diet, exercise, alcohol and smoking, work and leisure activities).

Examination:

• Check blood pressure using a large arm cuff.

Investigations:

• Check blood glucose and lipid profile, preferably on a fasting sample.
• Consider other tests if appropriate on the basis of assessment findings (e.g. liver function tests, thyroid function tests).

• Comorbidities should be managed at the time they are identified; treatment should not be delayed until the person has lost weight [NICE, 2006b].
• Investigations can be useful in that they act as a baseline for future measurements [National Obesity Forum, 2006].

• This recommendation is based on guidance from the National Institute for Health and Clinical Excellence on the prevention, identification, assessment, and management of overweight and obesity in adults and children [NICE, 2006b], the Department of Health care pathway for the management of overweight and obesity [DH, 2006a], guidelines from the National Obesity Forum [National Obesity Forum, 2006], and a review of obesity published in the Lancet [Haslam and James, 2005].

• Calculate the person's body mass index (BMI) if this has not already been done.
• Measure waist circumference in people with a BMI less than 35 kg/m².
• Using this information and Table 1, assess whether the person is at increased risk of cardiovascular and metabolic complications. Although different cut-off points are generally not recommended for different populations, use clinical judgement for certain people — Asian people may be at higher risk and older people at lower risk for a certain BMI compared with the general population.
• Ask about family history of diabetes (including gestational diabetes) and coronary heart disease.

• For people with a body mass index (BMI) of less than 35 kg/m, waist circumference may be used as part of the risk assessment [NICE, 2006].
• Waist circumference is used to assess the amount of abdominal fat a person has, otherwise known as 'central' fat distribution [National Heart Forum, 2007].
• This should be measured around the midpoint between the lowest rib and the top of the right iliac crest [DH, 2006].

• This recommendation is based on guidance from the National Institute for Health and Clinical Excellence (NICE) on the prevention, identification, assessment, and management of overweight and obesity in adults and children [NICE, 2006], the care pathway for the management of overweight and obesity from the Department of Health [DH, 2006], and a review published in the Lancet [Haslam and James, 2005].
• Life-threatening problems are more likely to occur as body fatness increases, therefore identifying at what body mass index (BMI) the health risks to a person increase is important [National Heart Forum, 2007].
• Central obesity (assessed by waist circumference) is linked to higher risks of type 2 diabetes and coronary heart disease [National Heart Forum, 2007].
• People who are overweight (BMI 25–29.9 kg/m²) with a waist circumference of more than 94 cm in men and more than 80 cm in women, or people classed as obesity I (BMI 30–34.9 kg/m²) have an increased risk of developing long-term health problems. This risk increases proportionally to the person's waist circumference [NICE, 2006].
• If a person's BMI is equal to or greater than 35 kg/m², waist circumference does not add a great deal to the measure of risk provided by the person's BMI [National Collaborating Centre for Primary Care, 2006].
• The BMI of a person who is elderly has a lower correlation with their percentage body fat than in a young person, and is less strongly associated with cardiovascular morbidity. However, a reasonable correlation still persists [National Collaborating Centre for Primary Care, 2006].
• People from certain socioeconomic and ethnic backgrounds may be at greater risk of obesity, or have different beliefs about what is a healthy weight and weight management [NICE, 2006].
• Some ethnic groups (e.g. Asian people) have increased cardiovascular and metabolic risks at lower BMIs. There is no universal agreement whether the BMI classification should be adapted for this group [National Heart Forum, 2007]. However, NICE recommend that health professionals need to use clinical judgement when assessing risk factors in these groups of people [NICE, 2006]. The World Health Organization (WHO) have proposed BMI cut-offs for Asian adults of 18.5–22.9 kg/m² for a healthy weight, and 23 kg/m² or more for overweight: 23–24.9 kg/m² (at risk), 25–29.9 kg/m² (obesity I), and 30 kg/m² or more (obesity II) [WHO International Association for the Study of Obesity and International Obesity Task force, 2000].
• There is also no globally applicable grading system of waist circumference for ethnic populations, but the International Diabetes Federation (IDF) and the WHO have suggested waist circumference thresholds for Asian adults of 90 cm (35 inches) or more for men, and 80 cm (31 inches) or more for women (the IDF definition includes South Asian and Chinese populations only) [WHO International Association for the Study of Obesity and International Obesity Task force, 2000; International Diabetes Federation, 2005; National Heart Forum, 2007].

• Determine if the person wants to lose weight at the present time.
• Questions which may help to clarify a person's readiness to lose weight include:
• Are you concerned about your weight?
• How important is it for you to lose weight at the moment?
• Do you believe that you could lose weight?
• What would have to change in your life for you to be able to tackle your weight?
• Is your weight affecting your life in any way at the moment?
• Explore barriers to lifestyle change, for example:
• Lack of knowledge about food, and how diet and exercise affect health.
• Cost and availability of healthy foods and opportunity for exercise.
• Safety concerns.
• Lack of time.
• Personal tastes.
• Views of family and community members.
• Low levels of fitness, or disability.
• Low self-esteem and lack of assertiveness.

• Motivation depends on the person accepting that obesity is a medical disorder.
• It is estimated that less than one in five people are motivated to accept treatment to lose weight.
• Encourage motivation by offering support, encouragement, and follow up from a weight management team.

[Haslam and James, 2005]

• This recommendation is based on guidance from the National Institute for Health and Clinical Excellence on the prevention, identification, and management of overweight and obesity in adults and children [NICE, 2006b], the care pathway for the management of overweight and obesity from the Department of Health [DH, 2006a], and a review published in the Lancet [Haslam and James, 2005].

• Consider referral to a specialist obesity service if:  
• The underlying causes of overweight and obesity need to be assessed.
• The person has complex disease states and/or needs that cannot be managed adequately in either primary or secondary care.
• Conventional treatment has failed in primary or secondary care.
• Specialist interventions (e.g. very low calorie diet for extended periods or surgery) may be needed.

• This recommendation is based on guidance from the National Institute for Health and Clinical Excellence on the prevention, identification, assessment, and management of overweight and obesity in adults and children [NICE, 2006b].

• Explore why the person does not feel ready to lose weight.
• Offer the person the opportunity to return for further consultations when they are ready to discuss their weight again and are willing or able to make lifestyle changes.
• Give information on the benefits of losing weight, healthy eating, and increased physical activity (e.g. a 'Why weight matters' card — for more information see the Department of Health website www.dh.gov.uk).
• Stress that obesity has specific health implications and is not just a case of how a person looks.

• This recommendation is based on guidance from the National Institute for Health and Clinical Excellence on the prevention, identification, assessment, and management of overweight and obesity in adults and children [NICE, 2006b] and the care pathway for the management of overweight and obesity from the Department of Health [DH, 2006a].

• Aim to help the person increase their physical activity levels and improve their diet and eating behaviour.
• Consider the use of behavioural interventions to achieve this aim.
• When deciding on treatment type, consider the person's:
• Preferences.
• Degree of overweight or obesity.
• Level of risk (using body mass index and waist circumference, if appropriate).
• Comorbidities.
• Social circumstances.
• Previous treatments.
• The person's level of risk and their potential for health benefits from weight loss should be considered when deciding on the intensity of an intervention.
• The person should be given a copy of their main goals, according to their needs.
• Offer a level of support appropriate to the person's needs.
• Offer encouragement and praise for successes, however small.
• If a person declines intervention, offer them the opportunity to make contact in the future for support and advice if they change their mind.

• Any behavioural intervention should be delivered with the support of an appropriately trained professional.
• Behavioural interventions for adults should include the following strategies, as appropriate for the person:
• Self monitoring of behaviour and progress
• Stimulus control
• Goal setting
• Slowing rate of eating
• Ensuring social support
• Problem solving
• Assertiveness
• Cognitive restructuring (modifying thoughts)
• Reinforcement of changes
• Relapse prevention
• Strategies for dealing with weight regain

[NICE, 2006b]

• The level of behavioural intervention will depend on the availability of local resources.

• This recommendation is based on guidance from the National Institute for Health and Clinical Excellence (NICE) on the prevention, identification, assessment, and management of overweight and obesity in adults and children [NICE, 2006b].

• Waist circumference low (< 80 cm for women or < 94 cm for men): offer general advice on healthy weight and lifestyle.
• Waist circumference high (>= 80 cm for women or >= 94 cm for men): offer structured advice regarding diet and physical activity.
• Comorbidities present (such as type 2 diabetes, hypertension, cardiovascular disease, osteoarthritis, dyslipidaemia, and sleep apnoea): offer structured advice regarding diet and physical activity. Consider starting drug treatment once dietary and physical activity interventions have been evaluated.

• Recommendations for the level of intervention in someone who is overweight are from the National Institute for Health and Clinical Excellence (NICE) guidance on the prevention, identification, assessment and management of overweight and obesity in adults and children [NICE, 2006b].

• No comorbidities present: offer structured advice regarding diet and physical activity.
• Comorbidities present (such as type 2 diabetes, hypertension, cardiovascular disease, osteoarthritis, dyslipidaemia, and sleep apnoea): offer structured advice regarding diet and physical activity. Consider starting drug treatment once dietary and physical activity interventions have been evaluated.

• Recommendations for the level of intervention in someone with a body mass index between 30 and 34.9 kg/m² are based on the National Institute for Health and Clinical Excellence (NICE) guidance on the prevention, identification, assessment, and management of overweight and obesity in adults and children [NICE, 2006b].

• No comorbidities present: offer structured advice regarding diet and physical activity. Consider starting drug treatment once dietary and physical activity interventions have been evaluated.
• Comorbidities present (such as type 2 diabetes, hypertension, cardiovascular disease, osteoarthritis, dyslipidaemia, and sleep apnoea):
• Offer structured advice regarding diet and physical activity.
• Consider starting drug treatment once dietary and physical activity interventions have been evaluated.
• Consider referral for surgery.

• Bariatric surgery is recommended as a treatment option if all of the following criteria are fulfilled:
• The person has a body mass index between 35 kg/m² and 39.9 kg/m² and other significant disease (e.g. type 2 diabetes, hypertension) that could be improved if they lost weight.
• All appropriate non-surgical measures have failed to achieve or maintain adequate clinically beneficial weight loss for at least 6 months.
• The person is receiving, or will receive, intensive specialist management.
• The person is generally fit for anaesthesia and surgery.
• The person commits to the need for long-term follow up.
• Local criteria and policies on access to bariatric surgery may vary. Usually referral for surgery will be made via a specialist obesity management service.

• Recommendations for the level of intervention in someone with a body mass index between 35 and 39.9 kg/m² are from the National Institute for Health and Clinical Excellence (NICE) guidance on the prevention, identification, assessment and management of overweight and obesity in adults and children [NICE, 2006b].

• Offer structured advice regarding diet and physical activity.
• This may be via a specialised weight management programme where available.
• Consider starting drug treatment once dietary and physical activity interventions have been evaluated.
• Consider referral for surgery.

• Bariatric surgery is recommended as a treatment option if all of the following criteria are fulfilled:
• The person has a body mass index (BMI) equal to or greater than 40 kg/m².
• All appropriate non-surgical measures have failed to achieve or maintain adequate clinically beneficial weight loss for at least 6 months.
• The person is receiving, or will receive, intensive specialist management.
• The person is generally fit for anaesthesia and surgery.
• The person commits to the need for long-term follow up.
• Surgery should be considered as a first-line option in adults with a BMI greater than 50 kg/m² in whom surgical intervention is considered appropriate. Antiobesity drugs should be considered whilst the person is waiting for surgery.
• Local criteria and policies on access to bariatric surgery may vary. Usually referral for surgery will be made via a specialist obesity management service.

• Recommendations for the level of intervention in someone with a BMI greater than or equal to 40 kg/m² are from the NICE guidance on the prevention, identification, assessment, and management of overweight and obesity in adults and children [NICE, 2006b].

• Advice on dietary changes should take into account the person's food preferences and allow for flexible approaches to reducing calorie intake.
• Promote a diet which is in line with healthy eating recommendations, is acceptable to the person, and is sustainable in the long term.
• Ensure that the person is aware of the changes they will need to make to their usual eating habits.
• All healthy people over 5 years old should eat a balanced diet rich in fruit, vegetables, and starchy foods including:
• Five portions of a variety of types of fruit and vegetables each day.
• Meals based on starchy foods (e.g. bread, pasta, rice, and potatoes) — include high fibre varieties if possible.
• Moderate amounts of milk and dairy products — should be low fat if possible.
• Moderate amounts of protein-rich foods (e.g. meat, fish, eggs, beans, and lentils).
• A reduction in the amounts of foods high in fat (especially saturated fat), sugar, and salt.
• A reduction in alcohol intake (alcohol is high in calories).
• Cooking using methods which reduce fat (e.g. grilling, steaming).
• People should be encouraged to improve their diet even if they do not lose weight.
• Diets that are recommended for sustainable weight loss in combination with expert support and intensive follow up are:
• Those with a 600 kcal/day deficit (i.e. they contain 600 kcal less than the person needs to stay the same weight), or
• Those which reduce calories by lowering the fat content (low-fat diets).
• Low-calorie diets (1000–1600 kcal/day) are less likely to be nutritionally complete, but can be considered in combination with expert support and intensive follow up.
• Do not use unduly restrictive and nutritionally unbalanced diets.

• The 'Your Weight, Your Health' booklet available from the Department of Health website, www.dh.gov.uk is aimed at people who are ready to address their weight, and discusses diet as part of a healthy life [DH, 2006b].
• Very-low-calorie diets (less than 1000 kcal/day) may be used, under specialist clinical supervision, for a maximum of 12 weeks continuously, or intermittently with a low-calorie diet (for example for 2–4 days a week), if a person is obese and has reached a plateau in weight loss.
• Any diet of less than 600 kcal/day should be used only under specialist clinical supervision.
• In the longer term, people should move towards eating a balanced diet, consistent with other healthy eating advice.

• This recommendation is based on guidance from the National Institute for Health and Clinical Excellence on the prevention, identification, assessment, and management of overweight and obesity in adults and children [NICE, 2006b] and the associated NICE quick reference guide [NICE, 2006c]. Recommendations for healthy eating are based on the Balance of Good Health from the Food Standards Agency [DH, 2006a; National Heart Forum, 2007].
• There is evidence to suggest that dietary interventions in people with overweight or obesity are effective in terms of weight loss, and that this effectiveness is increased when dietary interventions are combined with physical activity [National Collaborating Centre for Primary Care, 2006].
• Unduly restrictive and nutritionally unbalanced diets should not be used, because they are ineffective in the long term and can be harmful [NICE, 2006b].
• People should be encouraged to improve their diet even if they do not lose weight, because there can be other health benefits [NICE, 2006b].

• Any advice given about exercise activities and duration should consider the person's current physical fitness and ability.
• If appropriate, encourage the person to:
• Reduce the amount of time they spend being inactive (e.g. watching television or using a computer).
• Do at least 30 minutes of at least moderate intensity exercise on 5 days a week or more (this can be in one session, or split into a number of sessions lasting at least 10 minutes).
• Build up to these recommended levels, encouraging the person to set realistic goals, and to adjust these as their physical fitness improves.
• Recommended types of physical activity include:
• Activities that can be incorporated into everyday life, such as brisk walking, gardening, or cycling.
• Supervised exercise programmes.
• Other activities (e.g. swimming, aiming to walk a certain number of steps each day, or stair climbing).

• A pedometer may be useful for motivation and to help a person monitor their activity levels. If appropriate, adults can gradually work towards a goal of 10,000 steps a day [DH, 2006b].
• The 'Your Weight, Your Health' booklet available from the Department of Health website www.dh.gov.uk is aimed at people who are ready to address their weight, and discusses incorporating exercise into a healthy life [DH, 2006b].

• This recommendation is based on guidance from the National Institute for Health and Clinical Excellence (NICE) on the prevention, identification, assessment, and management of overweight and obesity in adults and children [NICE, 2006b].
• There is evidence to suggest that physical activity in people with overweight or obesity is effective in terms of weight loss, and that this effectiveness is increased when dietary interventions are combined with physical activity [National Collaborating Centre for Primary Care, 2006].
• Adults should be encouraged to increase their physical activity even if it does not result in weight loss, because of the other health benefits physical activity can provide (e.g. reduced risk of type 2 diabetes and cardiovascular disease) [NICE, 2006b].
• NICE have also produced a public health guidance entitled 'Four commonly used methods to increase physical activity: brief interventions in primary care, exercise referral schemes, pedometers, and community-based exercise programmes for walking and cycling' which can be accessed at www.nice.org.uk [NICE, 2006a].

• Only consider drug treatment after dietary, physical activity, and behavioural approaches have been started and evaluated.
• Consider starting drug treatment in people with:
• Body mass index (BMI) 27–35 kg/m² with comorbidities present. (Note that neither anti-obesity drug is licensed for use below a BMI of 27 kg/m²).
• All people with a BMI >= 35 kg/m².
• Only consider drug treatment as part of an integrated approach to weight management, which should include advice, support, counselling on diet and physical activity, and behavioural strategies.

• This recommendation is based on guidance from the National Institute for Health and Clinical Excellence on the prevention, identification, assessment, and management of overweight and obesity in adults and children [NICE, 2006b].

• Orlistat is the anti-obesity drug of choice when drug treatment is considered to be appropriate in primary care.
• The decision to use drug treatment should be made after discussing with the person the potential benefits and limitations of using orlistat, including the mode of action, adverse effects, and monitoring requirements (see Prescribing information for further information).
• Sibutramine is no longer prescribable in the UK — its marketing authorization has been suspended by the European Medicines Agency.

• These recommendations are based on guidelines published by the National Institute for Health and Clinical Excellence [NICE, 2006b; NICE, 2008].
• There is good evidence that orlistat is effective in improving weight loss compared with placebo [NICE, 2006b]. After 12 months the median weight loss with orlistat (in combination with a weight-reducing diet) was 5.4 kg (range 3.3 to 7.6 kg).
• On 23 October 2008 the European Medicines Agency's (EMEA) Committee for Medicinal Products for Human Use (CMHP) recommended the suspension of the marketing authorisation for rimonabant because the benefits no longer outweigh the risks [EMEA, 2008].
• Following the assessment of the available information on the benefits and risks of rimonabant, including data from studies completed since it was granted marketing authorisation, the CHMP confirmed that there is an approximate doubling of the risk of psychiatric disorders in obese or overweight people taking rimonabant compared to those taking placebo.
• Prescribers should not issue any prescriptions for rimonabant and should review the treatment of anyone currently taking it.
• On 21 January 2010 the EMEA recommended the suspension of the Marketing Authorisation for sibutramine because the benefits no longer outweigh the risks [EMEA, 2010].
• Data from the SCOUT trial (designed to determine the impact of weight loss with sibutramine on cardiovascular problems in overweight and obese people; 10,000 participants enrolled for up to six years) showed an increased risk of non-fatal cardiovascular events such as stroke and heart attack with sibutramine compared with placebo. The EMEA also notes that the weight loss achieved with sibutramine is modest in comparison with that obtained with placebo and it is not clear if this effect on weight loss can be maintained when sibutramine treatment is stopped.
• Prescribers should not issue any prescriptions for sibutramine, and should review the treatment of anyone currently taking it.